Paediatric Survival guide for pharmacists in

Critical Care

J. Persaud MSc,IP FFRPS,

Consultant CCS Pharmacist,

Sandwell and West Birmingham NHS Trust

OBJECTIVES OF SESSION

To provide a survival guide for pharmacists with paediatric

patients on ccs:- Medicines Reconciliation

Prescription monitoring :-including wt estimation

Fluids volumes (mls/Kg)

Differences in Physiological parameters BP & HR &UE’s –adults & children

Common conditions

IV compatibility & infusions & access

Renal failure & Haemofiltration

Calculating Sodium Contents

Minimising fluid volume

Medicines reconciliation

NICE / NPSA 2007 - Specifically excludes <16yrs

Continue as normal treat as for adults.

Evidence:-Chi Huynh et al showed med recon

important in paediatric population.

Results:

1004 medication regimens were included from the 244

patients across 4sites.

588 of the 1004 (59%) medicines, had discrepancies

between the PAM & Drug Chart; of these 36% (n = 209)

were unintentional &included for clinically assessment.

189 drug discrepancies 30% were classified as class 1,

47% were class 2 and 23% were class 3 discrepancies

Prescription monitoring

Role of ITU pharmacist is to ensure

all prescriptions are monitored ,safe & effectively

Fluids prescriptions in neonates & paediatrics

Infusion Calculations & use of PICU spreadsheet –Kids infusions

Awareness of diagnosis & disease conditions- as may have to modify Rx

Need to look at Paediatric U&Es & Haematology

Need to ensure can administer drugs thru’ lines /routes available

Tdm is this required ?

Estimating weight

Gold standard :- APLS formula wt = 2 x (age +4)

But evidence suggests:-

Luscombe M D, “Kids aren’t like what they used to be”: a study of paediatric patient’s weights and their relationship to current weight estimation formulae. British Journal of Anaesthesia 2005; 95(4): 578

Weight = 2x(age+5)

Whilst not as accurate on average as the other formula tried, it is:

1) More accurate than Weight = 2x(age+4)

2) Likely to avoid drug over-dosage

3) Simple to calculate

BNFc –wt & ht

Body surface area and wt <40kg

Body wt S.A > 40kg

WETFLAG accronym Yes, the EPALS course uses the simple acronym W E T Fl A G for children over the age

of 1 year and up to 10 years old. This equates to:

W Weight (Age + 4) x 2 (kg)E Energy/electricity 4 x weight (kg) = JoulesT Tube (endotracheal) Age/4 plus 4 = ID mm (uncuffed tubes)Fl Fluids (bolus) 20 x weight (kg) = mL of isotonic fluid (caution in some cases)A Adrenaline 10 mcg kG-1 1:10000 solution = 0.1 mL kg-1

G Glucose 2 mL kg-1 (10% Dextrose)

Example For a 2 year old child:W = (2 + 4) x 2 = 12 kgE = 12 x 4 = 48 JT = 2/4 +4 = 4.5 mm ID tracheal tube uncuffedFl = 20 mL x 12 kg = 240 mL 0.9% salineA = 10 micrograms x 12 kg = 120 micrograms 1:10,000 = 1.2 mLG = 2mL x 12 kg = 24 mL 10% Dextrose

Whilst this is not evidence based, it provides a simple, easy to remember framework in a stressful situation reducing the risk or error.

June 2016

Resus Council 2016

BAPM standards document

Neonatal physiology

Brief information about neonatal fluid prescribing

Physiology at birth

Neonates have expanded extracellular fluid (ECF) compartment, with premature babies having ECF of 85% of Body wt & term babies 75% (compared to adults with approx 60%)

A physiological diuresis (driven largely by Atrial Natruretic Peptide) causes the ECF compartment to contract during the first days after birth, resulting in a negative Na /H20 balance during this time.

Fluids should be restricted during this period, & too liberal fluid regimes have been shown to cause increased incidence of PDA, Necrotising enterocolitis, & worse overall mortality in premature infants.

Reference :Kearns GL et al. Developmental pharmacology – drug disposition, action and therapy in infants and children. NEJM 2003; 349: 1157-67

Things to consider before prescribing to

neonates

Body composition for drug distribution

Total body water and fat changes with age

Preterm Term 3

months

adults

TBW 85% 75% 75% 60%

ECF 50% 40% 30% 20%

Body fat 3% 12% 15% 18%

Reduced renal function

GRF Birth 2-3 days

Preterm 0.7-0.8 mls/min 2-3 mls/min

Term 2-4 mls/min 8-20 mls/min

GFR takes 3-5 months to attain adult values

Risk of nephrotoxicity from gentamicin

This why fluid balance is critical in neonates

Prescribing for neonates

IV- fluid requirements, 60,90,120 and 150ml/kg

IA lines

Multiple infusions / check with MDT/ formulary

Small volumes should be given slowly

Long half life so can be given OD or BD some

levels are required

Drugs are formulated for adults may need

further dilution

Stop drugs asap

References:Esphergan 2003

IV Fluid considerations in neonates

Prematurity – prem babies have increased fluid requirements, as have high insensible loses result of their thin, immature skin allows significant evaporative (heat) losses. Humidication in an incubator is very important to minimise losses.

Hypoxic ischaemic injury - babies can need fluid restriction as a result of acute renal impairment or raised ADH levels. Can become hypocalcaemic early.

Hypernatraemia/hyponatraemia - plasma Na should be monitored at least daily, & up to 2-3 times daily in extremely preterm babies. Good guide to hydration status, where hypernatraemia (>145 mmol/L) = dehydration and hyponatraemia (< 135 mmol/L) = water excess.

Urine output - should be monitored carefully, aiming for > 1 ml/kg/hr.

Electrolytes replacement -Neonates

Sodium Potassium Calcium

< 30 weeks 4 - 8 2 - 4 1.5

30-36 weeks 4 2 0.5 - 1.5

Term 2 - 3 2 0.5

Electrolyte requirements (mmol/kg/day)

Paediatric fluid volumes

Less than 10kg =100 ml/kg/day or 4ml/kg/hour

10-20kg 1000ml plus 50ml/kg/day for each kg over 10kg

or 40ml/hour plus 2ml/kg/hour for each kg >10kg

over 20kg=1500ml plus 20ml/kg/day for each kg >20kg or 60ml/hour plus 1ml/kg/hour for each kg over 20kg

Up to a maximum of 2500 ml/day in males and 2000ml/day in females

NICE fluid requirements in children

NICE Fluid requirement 2

Fluids requirement –maintenance

Fluid requirements-replacement & re-distribution

Managing hypernatreamia Na>145mmol/l

Paediatric IV fluids

What you need to know

Careful assessment & monitoring of wt, fluid balance, & fluid status essential for IV fluid therapy in children, as is the correct choice of fluid, to avoid serious complications including death &neurological injury

To reduce anxiety & improve compliance with blood tests, explain their importance to children who understand & for carers; consider distraction techniques & comfort measures in younger children and use topical local anaesthetics before taking blood

Isotonic crystalloids with a Na+ content of 131-154 mmol/L are appropriate for initial maintenance requirements

In children receiving IV fluids, symptoms such as N & Vomiting, lethargy, confusion, and irritability may indicate hyponatraemia.

Medical emergency requiring immediate expert advice & treatment

KIDS website for guidelines infusionhttps://kids.bwc.nhs.uk/healthcare-professionals-2/clinical-guidelines/

https://kids.bwc.nhs.uk/healthcare-professionals-2/clinical-guidelines/

https://kids.bwc.nhs.uk/healthcare-professionals-2/app/

Bronchiolitis

BSPED DKA

Calculator

British Inherited

Metabolic Disease

group

Calcium Gluconate

Button battery

ingestion

Drug infusions guide PICS standards Tranexamic Acid

monograph

Diabetic Ketoacidosis

(DKA)

Pre-intubation checklist PICS UK website Vasopressin

Difficult airway

guideline

Neurosurgical

emergency

RCPCH - High

Dependency Care

Fluid and

electrolyte therapy

Emergency

tracheostomy teaching

slides (NTSP)

OPENPediatrics - World

Share Practice Forums

Hyperammonaemia/

Metabolic emergencies

Emergency

tracheostomy SOP

Massive haemorrhage

(BCH)

NTS guidelines

Major Trauma (BCH) ETT strapping (oral)

technique

PDA drive through SOP

Severe Sepsis & Septic

Shock

Endotracheal intubation

guideline

PDA drive through

proforma

Status epilepticus Neonatal network-

guidelines 2015-17

SVT

What patients might you see ?

KIDS infusion calculator

https://kids.bwc.nhs.uk/healthcare-

professionals-2/drug-calculator/

Sample of drug dose calculator

KIDS guidelines on IV fluids

Commonly disease conditions

Dka – BSPED & Local /kids calculator

Sepsis –NICE Quality standard [QS161] Published

date: September 2017

Respiratory tract infection-local

Status epilepticus-NICE Epilepsy in children and young

people Quality standard [QS27] Published date: February 2013

Asthma www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-

asthma-guideline-quick-reference-guide-2016/

Trauma & NAI

Question 1

A two year (12kg) child needs IV

fluids based on the table above:-

a) Calculate fluid requirement for 24 hours assuming no other problems ?

- Using Kids calculator

- 0-10kg 100mls/kg x 10 =1000ml

- 10-12 50mls/kg x 2 = 100ml

- Total = 1100ml per 24 hrs

Calculate Infusion rate of IV fluid

a) 1100mls/24 =45.8ml/hr

Physiological targets

What else differs in children ? (1)Age BP (sys)(mmHg) HR RR

<1 70-90 110-160 30-40

1-2 80-95 100-150 25-35

2-5 80-100 95-140 25-30

5-12 90-110 80-120 20-25

>12 100-120 60-100 15-20

MAP and children age

What UEs differ in children

term pre-term

Base Excess mmol/l -5 to +5* -3 to +3*

Creatinine μmol/l 76 –156 37 –113

Calcium mmol/l 1.9 – 2.7 2.1 –2.7

Glucose mmol/l 2.6 – 5.5 2 – 5.5

Lactate mmol/l 0.5 – 2.2 0.5 – 2.2

Mag mmol/l 0.62 – 1.2 0.7-1.0

Phosp mmol/l 2.0 – 3.0 * 1.7 –2.6**

Potas mmol/l 3.5 – 6.0* 3.5 – 6.0**

Sodium mmol/l 135 – 146 135 -146

Urea mmol/l 2.0 – 5.0 3.4 – 6.7

IV access & compatibility and access for

infusions

Commonest problem is access

Polypharmacy due to multipathology

Sedation,analgesia,inotropes and antibiotics

Practical considerations:-

What can be given peripherally &centrally

Use of Medusa &minimum volume guide

Issues such as osmolality & pH

Infusions practical issues (1)

PICU- infusion table- Calculations

Experience of compatibilities

•Inotropes

3 of the following

Adrenaline,Noradrenaline,Dopamine,

Dobutamine & Milrinone

Sedation

Morphine + Midazolam+Rocuronium

Anecdotal experience

Infusion practical issues (2)

TPN – again some limited information on

Heparin & y site but low concentrations

Dopamine & y site

Dobutamine & y site

Vancomycin & y site

General rule discourage but have done

Remember you can monitor the outcome

Network bags for neonates !!

Infusions practical issues (3)

Access

•Have you got a central line ?

•Is it a triple or quad lumen ?

•What peripheral canula

•Use of CVP line

•Problems in neonates and prems – UAC /UVC ?

Other problems

•Problem of Sodium loads

•Problems of hyperglycaemia

•Problems with PN

Renal failureWhat is renal failure & how do you measure RF ?

a)Adults-cockcroft gault 1.23**x 140-age*wt/srCr or 1.04** for female (Can not use)

b)Children > 1yr (Schwarz eqn)41.3 x Height(metres)/Sr Cr (Sr Cr =mg/dl)

GFR,

mL/min/1.73

m²

CKD stage Severity

≥90 1 Normal

60-89 2 Mild

45-59 3a Mild-moderate

30-44 3b Moderate-severe

15-29 4 Severe

<15 5 End-stage

For reference, age-specific normal ranges for GFR are provided here. Standard CKD staging (e.g. for medication dose adjustments) is as above.

Question 2

A 3 month baby is anuric & the

weight is 5kg and Cr=120 ,length

= 65cm

Calculate approximate gfr =20ml/min ckd stage 4

This baby is on aciclovir IV 10mg/kg

8 HRLY for encephalitis – please comment ?

Renal replacement therapies (RRT)

PD-oldest form peritoneal dialysis use of

Peritoneum as semi-permeable membrane –works well in paeds uses 1.36% & 3.86% p.d solutions

CVVH-haemofiltration –ultrafiltration & blood pump sieving effect approx GFR=10-20ml/min

CAHD-haemodialysis most efficient 20% of r.f

Dialysis fluid introduced counter current-diffusion & ultrafiltration

CAVHD combination of CVVH & CAHD

RRT (2)

What is the impact of RRT for patient ?

Remove fluid &solute

Impact on drug clearance

Dose adjustment

TDM

Sources of information MFC & renal handbook

Drugs in renal impairment & spc

BNF appendix

Respiratory Support

Why is ventilation so important ?

What are the different modes of

ventilation-CMV,SIMV,CPAP & BIPAP &

HFO –works in neonates

What are the implications for p’cists

What electrolytes do you monitor ?

Why do you need sedation ?

Sedation & analgesia

Morphine

Remifentanil

Alfentanil

Fentanyl

Clonidine

Midazolam

Liver disease

Monitor LFTs:-Bilirubin,enzymes,alk phos,gamma GT,Albumin ,coagulation

Issues care with sedative drugs

Drug clearance reduced

Support clotting & GI bleeds / varices

Low sodium load

Low protein load

Nutrition -PN

Line infection

Metabolic complications:-

Fluid overload or dehydration

Hyper/hypoglycaemia

Respiratory distress xs glucose

Acute lipid reaction

Hyperlipidaemia

Hyperammonaemia

Hyperchloraemic acidosis-use acetate

Compatibilities

Stress ulcer prophylaxis

90% of patients without prophylaxis or

gastroprotection will ulcerate

Use of ranitidine

Use of PPIs-omeprazole doses

proportionally > in paeds

Use of trophic feeds

Inotropes

Use kids infusion guidance

Dobutamine

Dopamine

Adrenaline

Noradrenaline

Other drugs - antibiotics

Sepsis & Septic shock –use of cefotaxime

Meningitis –care neonatal 28d – 3month

May be GM –ve

Gp B strep

Listeria

Use cefotaxime & amoxicillin

Other infections

Neutropenia –pip / tazobactam

CAP amoxicillin

2nd choice azithromycin

HAP 1st choice amoxicillin

2nd choice azithromycin or

Clarithromycin

UTIs –treat very aggressively

Antibiotics - refer separate guidelines

Penicillins – mainly Ben Pen &Co-Amoxiclav

Cephalosporins – mainly for UTIs /sepsis/meningitis

Macrolides- clarithromycin preferred

Quinolones- caution due cartilage damage

Others;teicoplanin,

Carbopenems - meropenem

Antifungals – fluconazole / caspofungin/ambisome

Antivirals – aciclovir for encephalitis

Sources of information

BNFc

Neonatal Formulary 5 for Neonates

NPPG network

Guy’s Paediatric Formulary

Guideline folder for paediatrics

Colleagues

Questions